Thou shall not die: Reducing maternal deaths in sub-Sahara Africa

There is growing optimism in the development community that the dawn of the “African Century” may be upon us. The reasons for this optimism are real. Over the last decade, six of the world's 10 fastest-growing economies were in Africa, and substantial political and social progress has been achieved.

But I would say that the potential for this development may be undermined if the everyday tragedy of preventable maternal deaths continues unabated across the continent.

The recently-released report “Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates” paints a dramatic picture. Overall, close to 60% of global maternal deaths occur in sub-Saharan Africa, and at 500 maternal deaths per 100,000 live births, the region has the highest maternal mortality ratio (MMR) in the world, well above Southern Asia (220), Oceania (200), South-eastern Asia (150), and Latin America and the Caribbean (80).

While Sierra Leone (890), the Central African Republic (890), Burundi (800), Guinea-Bissau (790), Liberia (770), the Sudan (730), Cameroon (690), and Nigeria (630) had very high MMRs, Chad and Somalia had extremely high MMRs at 1100 and 1000, respectively.

The data also show that for many sub-Saharan African countries it will be difficult and in some cases impossible to achieve the Millennium Development Goal (MDG) 5 target of reducing maternal mortality by 75% between 1990 and 2015. That is the case of countries such as Zambia (440) and Kenya (360) that show insufficient progress, or Zimbabwe (570) and South Africa (300), with no measurable progress over the last 20 years.

Although the MMR has started to decline in some countries, such as Botswana, Lesotho, Namibia, South Africa and Swaziland, due to the increased availability of antiretroviral drug therapy for HIV infected people, they are not expected to meet the MDG5 target. Equatorial Guinea, with an 81% reduction achieved by 2010, is the only African country that has already met the MDG 5 target.

The situation in the sub-Saharan countries was common in the United States, Australia, New Zealand, and continental Europe up to the late 1930s, when dramatic declines began to occur. This was due in large measure, according to a historical account by Irvine Loudon, to successive improvements in the quality of maternal care services, including the adoption of simple hygienic measures such as mandatory hand washing by doctors before patient examination and the use of antibiotics to prevent and control bacterial infections contracted by women during childbirth that were often fatal.

While vaccination, distribution of insecticide-treated bednets, vitamin A supplementation, and deworming, that help reduce child mortality, can be delivered according to a “predeterminate” schedule or “outside” health facilities, acute or emergency care services for dealing with pregnancy complications that in most cases cannot be predicted and prevented require a well organized and run health system.

So, if we heed the lessons from history, a renewed push needs to be placed on expanding the referral and emergency obstetric care capacity in the African health systems, including well trained, incentivized, and supervised teams of community health workers, midwives, nurses and doctors, to provide quality services to deal with direct obstetric complications, which occur around the time of childbirth and cause more than 60% of maternal deaths: hemorrhage, hypertensive disease, sepsis/infection, obstructed labor and other direct causes. Well funded and accessible voluntary family planning services would also contribute by reducing unwanted pregnancies and thus the risk of maternal death. And the development of accurate data systems is vital not only for keeping track of the number and causes of maternal deaths, but also for evidence-based policy-making and performance management and evaluation.

There are “demand” factors as well. Since care at the time of birth is crucial for saving mothers and newborns, reducing barriers that prevent pregnant women from going to health facilities, particularly in regions with poor road infrastructure, challenging terrain and limited transport options, cannot be ignored. Addressing these factors will require new approaches, such as innovative community transport schemes when ambulances are not available, alongside efforts at the community level to raise knowledge of maternal and newborn danger signs that often go ignored.

As the “African Century” evolves, sustained reductions in maternal deaths should be seen as a “critical marker” to gauge its progress and impact on improving the lot of society as a whole.

Comments

Dear Patricio,
Thanks very much for this blog and for raising awareness on maternal mortality, which continues to get enough attention - despite being part of the MDGs. As you rightly pointed, many childbirth-related complications are unpredictable and a key factor in lowering both maternal and child mortality is the presence during childbirth of a skilled attendant or person with skills in midwifery and access to the necessary equipment for effective management of complications. Often, from my experience working in the transport sector, we have seen that many women do not have access to this care and it becomes even more difficult in case of emergency. We must work across sectors to identify bottlenecks locally and monitor the success of where any improvements can be made. We know of countries like Malaysia and Sri Lanka where significant reductions in maternal deaths happened. And it took a multisectoral approach to tackle the typical 3 delays to access care (assuming there is good care at the end of the road/ transport):
http://blogs.worldbank.org/transport/transport-and-maternal-health-president-zoellick-agrees-with-me
Best, Julie

Indeed Julie. This is another example of a condition that requires to be addressed as a broad social problem and not only as a health sector issue. While a well running health system will help reduce unnecessary maternal deaths, this benefit will only be generated if the pregnant women, family members and community after recognizing the signs of complications are able to transport the woman to a health facility. If not, lack of transportation or delays in reaching the facility will contribute to preventable deaths.

If this is the African century, let's hope that it will not have hundred years duration.In my view the situation is gloomier.In fact these data are based on information provided by governments. They most probably do not reflect the real figures, which I believe are higher. Still in some African countries, women give birth in the villages far from any qualified medical assistance. Even when there are hospitals, in some medical structures, windows are broken letting all kinds of dust to enter in the surgery platforms, there is no water nor electricity nor sufficient hygienic conditions.
In the main hospitals in Conakry, Guinea, after delivering new mothers can eat only if their families bring food. Often, they may sleep on the ground. They were only 6 incubatory units for the whole country. Therefore the lives of both mother and child are at a very high risk.

The issue of underreporting is a real problem. As suggested in the blog,the development of accurate data systems is vital not only for keeping track of the number and causes of maternal deaths, but also for evidence-based policy-making and performance management and evaluation.

Hi Patricio,
thanks for the great blog. I read the summary of the recent maternal mortality estimates. if I remember correctly, one of the large contributors in many African countries was complications from illegal abortions. Bill Clinton said it eloquently - in the ideal world, abortion would be "safe, legal and rare"; rare because there would be far better access to contraception. I know this is a sensitive topic, but would hope it could be part of the discussion.

Joy: your comment is right on the mark. Indeed, unsafe abortions in unhygienic conditions contribute to hemorrhage and sepsis/infections, the leading direct causes of maternal deaths in Africa. And unsafe abortions ocurr in countries where abortion is illegal or where access to voluntary family planning services is limited.

Colleagues, my heart bleeds when I analyse realities on the ground as regards to increased child mortality in some African countries including mine! In their detailed study titled ` Assessing donor assistance to marternal, newborn and child health between 2003 and 2006, Giulia Greco etal, reveals that aid towards these areas increased from USD2119 in 2003 to USD3482 (64%). Instead of experiencing a general improvement, we see the opposite in the welfare of children. Where are we missing the point in this fight? Please colleagues in Sub Saharan Africa help me to understand.

Your point is very important. Aid effectiveness is a critical challenge that requires not only donor harmonization, but I would say more importantly the political commitment and mechanisms at national governments to ensure that donor funds are used well for the intended purposes. And this in turn requires that governments and donors alike support the development of sustainable institutions and national capacity over the medium term (e.g., well run health systems and programs). Short term measures will not solve the problem.

Hi Patricio,
Thanks for your blog - on the need to redouble efforts at reducing maternal mortality in SSA and achieving the MDG goal. I agree with you on the need for government/policy makers to tackle demand, supply and behavioural factors that constrain access and utilisation of maternal healthcare in SSA. On the demand side, one important point you failed to mention, which has proven to be an effective strategy for reducing mortality levels, is the removal of user fees in maternal and child healthcare services. For instance, in Mali [http://www.globalhealthcheck.org/?s=mali], Seirra Leone [http://www.globalhealthcheck.org/?p=699], Burkina Faso[http://www.globalhealthcheck.org/?p=203], Haiti etc, there were significant reductions in maternal and child mortalities and an increase in service utilisation among poorest women when user fees in maternal and child care were removed. Hence, reducing access barriers should take into account the need to address financial barriers as well. This is because user fees in healthcare are the most important constraining factor for maternal healthcare in SSA, and not just the transportation problems or the unavailability of obstetric healthcare facilities.
Thanks

Thanks for your comment as the barriers to access and utilization are multiple, not just geographical or cultural. Financial barriers are real impediments as you noted. A great challenge in the African context, as in several countries elsewhere, is how to move forward incrementally and in a sustainable manner towards universal financial protection in health, particularly among vulnerable population groups. And this would require added efforts to mobilize funding, both increased tax funding of health care and under health insurance schemes. But let's keep in mind that funding alone will not solve the problem as there is the need for parallel efforts to improve access to, and the use of, quality services delivered in well run health systems. These challenges should be seen as part of a medium term process that requires political commitment at the highest level, honesty and transparency in the use of public funds, and a well defined road map to put in place sustainable arrangements or building blocks for an effective health system: from health care organization and related infrastructure and technological investments, supply chain arrangements, trained staff, predictable funding, quality assurance mechanisms, and performance management.
The excellent speech by US Secretary of State Clinton "A World in Transition: Charting a New Path in Global Health" delivered in Oslo on June 1, 2012, makes some interesting points concerning to the above discussion. A good reading: http://www.state.gov/secretary/rm/2012/06/191633.htm

Results of recent research published in The Lancet, ahead of a major international gathering taking place in London this week sponsored by the British Government and the Gates Foundation, clearly indicate that a large proportion of maternal deaths can be averted at moderate cost through scaled up access to family planning services.
An analysis of 172 countries by Saifuddin Ahmed, Qingfeng Li, Li Liu, Amy O Tsui of the Johns Hopkins University Bloomberg School Public Health estimated that 342 203 women died of maternal causes in 2008, but that contraceptive use averted 272 040 maternal deaths (44% reduction), so without contraceptive use,the number of maternal deaths would have been 1·8 times higher than the 2008 total. Satisfying unmet need for contraception could prevent another 104 000 maternal deaths per year (29% reduction).

There are two issues in addressing high maternal mortality in sub saharan Africa. the first and most important one is improving the quantity ant quality of human health resource without any emphasis on cerificate, lets just provide the skills to trainable and willing community brains that are willing to serve. the second is to reduce absolute corruption to enable resource managers provide some fund to procure the needed equipments and consumables to health facilities.

Thanks for your comments. Indeed, human resources limitations faced in most of the health systems in sub-Saharan Africa severely constrains the capacity to deliver quality services. One way to address this challenge, in accordance with your suggestion, includes delegating tasks done by physicians to staff with lower level qualifications or someone without a formal education who has been specifically trained for that task. As I have noted elsewhere,the Global Forum for Government Chief Nursing and Midwifery Officers in May 2012 called for nurses and midwives to have an enhanced role in control of non-communicable diseases. And given that women with hypertensive disorders in pregnancy (pre-eclampsia or gestational hypertension) have been found to have a substantially higher risk of developing diabetes and cardiovascular risk factors, training nurses and midwives to identify and manage or refer women with these complications appropriately seems an effective approach to address the multiple health needs of women.

As reported by DONALD G. McNEIL Jr, in the The New York Times on October 30, 2012:
"The Bill & Melinda Gates Foundation has given a $5 million grant to a Massachusetts nonprofit group to work on a very specific problem: how to get new mothers in Ghana to hospitals.
Child mortality is very high in Ghana, but many newborns can be saved if the mother gives birth with someone trained, even rudimentarily, in Western medicine and if the baby is seen within two days by a doctor or nurse.
But in rural Ghana, explained Dr. Pierre M. Barker, vice president of the Institute for Healthcare Improvement, which received the Gates grant, there are many obstacles. Besides the obvious, like rutted roads, there are prejudices against wives or newborns leaving the house.
Sending expert committees to visit village chiefs, he said, has turned many into advocates for getting women to clinics instead of giving birth with untrained local midwives who may be unable to diagnose pneumonia or who have habits that cause tetanus, like cutting umbilical cords with dirty blades.
Dr. Parker described how his agency helped set up a village meeting that produced a way to get women in labor to hospitals when they had no money. He expected villagers to donate funds. Instead, local minibus-taxi drivers proposed a deal: They would carry the women at no charge if, once they arrived, they were allowed to jump the line for paying passengers headed back home.